**6. Fertility and assisted reproduction techniques: "when you want to propitiate the miracle despite the risks."**

Although there is no evidence that the disease itself decreases fertility, what we do know is that high levels of activity and the use of certain medications can affect the fertility of patients. Cyclophosphamide (CYC), which is the most well-known example of drug, can cause everything from menstrual irregularities to even premature ovarian failure. This will depend on the age of the patients and the dose used and accumulated. When the manifestations of SLE are mild, consideration should be given to not using any treatment that could be gonadotoxic or should be weighed against the risk of ovarian dysfunction. Consider ovarian reserve measures, especially in young patients, if you have important risk factors for a probable alteration of fertility. Usually, the most extensively studied method for the prevention of ovarian failure in patients with SLE includes treatment with gonadotropin-releasing hormone analogs (GnRH-a). This should be administered 22 days before starting or continuing CYC and preferably before starting immunosuppressive treatment.

Embryo and oocyte cryopreservation are options for preserving fertility in patients who are stable enough to safely undergo ovarian hyperstimulation. They are generally safe for patients.

Ovarian hyperstimulation syndrome is a rare complication that results in severe capillary leak syndrome and this increases the risk of thrombosis and renal compromise, which in turn could trigger a flare in patients. However, assisted reproduction techniques have good results and many patients, the vast majority, have been treated prophylactically with anticoagulants. It is imperative to consider prophylactic anticoagulation in patients with high-risk antiphospholipid syndrome and is mandatory for those with confirmed antiphospholipid syndrome. The usual regimen [low-dose aspirin with low-molecular-weight heparin (LMWH)] should be recommended as antithrombotic treatment during pregnancy according to the individual risk profile of each patient.

Concomitant therapy with GnRH analogs, usually leuprolide, appears to decrease the risk of premature ovarian failure. Addressing fertility problems in these patients requires a multidisciplinary collaboration on the part of the perinatologist, obstetrician, rheumatologist, and pediatrician, and this union of powers will make the result favorable and successful [43].

#### **7. Conclusions**

